Skin concern spotlight: Melasma:

Pigmentation is the natural colour of a person’s skin and it is related to melanin production. Melanin protects skin cells and their DNA by absorbing the sun’s ultraviolet rays (UVR).

Hyperpigmentation occurs when excess melanin causes a darkened appearance to the skin in either small or large areas.

Darker skin types, in general, are more susceptible to hyperpigmentation than lighter skin types because their skin naturally contains more melanin.

There are 3 common types of hyperpigmentation:

1) UV ray induced: From the sun or tanning beds. This type of hyperpigmentation shows in the form of freckles, age spots and uneven skin tone. 

2) Post-Inflammatory Hyperpigmentation (PIH): PIH is found in areas of the skin that have been subjected to inflammation due to trauma, acne or irritation (eg. fragrances or laser side effects).  Inflammation stimulates Langerhans cells (immune cells), which alter the activity of melanocytes (skin cells), causing increased pigment production.

3) Melasma (AKA chloasma): This appears as patches most often on the cheeks, chin, upper lip and forehead. It can be related to hormones eg pregnancy, the contraceptive pill, or menopause. 

The hyperpigmentation process:

1) Hyperpigmentation trigger (Inflammation, UV rays, or hormones)

2) Melanin production is stimulated within melanocytes. Tyrosinase is one of the key enzymes in this process.

3) Melanin is transferred from melanocytes to skin cells.

4) Skin cells are in a constant state of upward motion to the surface.

5) Skin develops dark spots or areas on the surface, or is uniformly darker (as in a tan).

Hyperpigmentation can become darker as the skin cells move closer to the surface. This point is important because, with many treatments, hyperpigmentation can darken in appearance before fading.

Melasma:

Melasma (from the Greek word, “melas” meaning black) is a common, acquired, patchy hypermelanosis (hyperpigmentation) of sun-exposed skin. 

The most common locations are the cheeks, upper lips, the chin, and the forehead, but other sun-exposed areas may also occasionally be involved. 

Causes of melasma:

Environmental and genetic causes:

Melasma occurs in all skin types and in people of all racial and ethnic groups, but is more common in those with darker complexions living in areas of intense UV radiation.

There is a family history of melasma in up to 30% of cases.

Hormonal causes:

Oestrogen/progesterone contraception or HRT: The incidence of melasma increases with the length of time for which the hormonal treatment has been taken. 

The incidence associated with the oral contraceptive pill is unknown but varies from 9% to 37%, with the higher incidence associated with sunnier climates.

Pregnancy: Melasma caused by pregnancy is called Cholasma, or the“mask of pregnancy”.

Most pregnant women have increased skin pigmentation, and around 5% get chloasma.

The probability of chloasma depends on sunlight exposure, genetic predisposition, and skin type. 

It usually resolves after the pregnancy. 

Medications:

Phototoxic (sun-sensitizing) drugs, especially phenytoin for epilepsy, can increase the risk of melasma.

Dermal or epidermal Melasma:

Melasma can be in the epidermal (top layer of the skin) layer or dermal (deeper) layer. 

A Woods lamp (blacklight) can help to distinguish between these forms of melasma in people with fair skin. 

This distinction is important as the epidermal form is much more responsive to treatment.  

Treatment of Melasma:

The pigmentation often fades spontaneously, particularly after the end of pregnancy, or on stopping oral contraceptives, although this is not always the case.

If it persists, melasma can be difficult to treat.

Sunblock:

Limiting exposure to UV rays is the most important treatment: People with melasma should use a sunscreen effective against both UVA and UVB with sun protection factor of 30 or greater, and should avoid the midday sun.

Physical treatments:

Intense pulsed light therapy has been used to treat melasma, and Laser treatment is often tried. However, neither seem to be particularly effective. 

Topical (cream) treatments:

Hydroquinone – 2, 4, or 5%. This It is a depigmenting agent; it inhibits tyrosinase, an enzyme needed for melanin synthesis. It also affects the membranes of melanocytes and causes their apoptosis (cell destruction).

Side effects can include redness, dryness, and even cracking of the skin. In rare cases, it can cause a condition called ochronosis, which is a bluish-black pigmentation of the skin.

Tretinoin – this works very slowly – the lightening of the melasma is often not apparent until after 24 weeks of treatment, if Tretinoin alone is used.It works better if used in combination with hydroquinone. 

Tretinoin acts in 3 ways: it helps speed the removal of pigment by accelerating the keratinocytes’ (epidermal cells) turnover, it enhances hydroquinone penetration into the skin, and it protects hydroquinone from oxidation. 

Tretinoin can be irritating to the skin in some people. 

Steroid creams – mometasone, fluocinolone or hydrocortisone – The addition of a corticosteroid cream can reduce inflammation which can be a side effect of both hydroquinone and tretinoin. Steroids also inhibit melanocyte metabolism.

Azelaic acid 20% –this has been shown to be an effective treatment for melasma and also post-inflammatory hyperpigmentation – it is the easiest formulation to use and best tolerated. The effect of azelaic acid can be attributed to its ability to inhibit the energy production and/or DNA synthesis of hyperactive melanocytes. It also has antityrosinase activity. 

Often, therapy with other creams can only be used for a limited time, and azelaic acid is used after this course has finished to maintain results.

Glycolic acid peels – There have been reports of chemical peels alone improving melasma, however they are more likely to be effective when used in conjunction with regular topical treatments of hydroquinone, tretinoin, and steroid.

Melasma can be treated with 1,2,3, or 4 of these treatments in combination, depending on severity of the condition, personal preference, and tolerance/side effects. 

Single therapy:

Azelaic acid, hydroquinone, tretinoin, or glycolic acid peels can be used alone.

Hydroquinone 4% alone is a commonly used first line treatment for mild melasma. 

Double therapy:

Azelaic acid and tretinoin:

If hydroquinone and steroid creams are unsuitable, the other 2 effective creams for melasma can be used together.

One study showed Azelaic acid with tretinoin caused more skin lightening after three months than azelaic acid alone, and a higher proportion of excellent responders at the end of treatment

Azelaic acid and hydroquinone:

If tretinoin is unsuitable, azelaic acid and hydroquinone can be used together, with better results shown than single therapy. 

Tretinoin and hydroquinone:

These can be used together without a steroid. 

Triple therapy formulations:

The gold standard of treatment is to use both of the best treatments for melasma – hydroquinone and tretinoin – and also a steroid to reduce the inflammation from these and further reduce melanocyte action.

Brands include:

Tri-luma” cream is a stable combination of fluocinolone acetonide 0.01%, hydroquinone 4%, and tretinoin 0.05%. This formulation is FDA approved. 

Pigmanorm” is a combination of hydroquinone 5%, hydrocortisone 1%, and tretinoin 0.1%.

The steroid cream Mometasone furoate can also be used – It can be added to hydroquinone and tretinoin creams to make up a triple therapy.

Having the creams separately has the benefit of being able to use the steroid component less frequently than the other ingredients – for example every second or third day. 

Long term use of steroid creams can cause redness, thread veins, and thinning of the skin. 

Therefore, triple therapy formulations should never be used long term – they are usually limited to 2-3 months use at a time.

Chemical peels in conjunction with triple therapy:

Serial chemical peels, when used as well as triple therapy, can create a more rapid initial response and more overall lightening of skin. 

3-4 weekly peels can be given. A course of 6 is usually required.

A 50 – 70% Glycolic acid has proven to be effective and safe to be used in this way.

Other options are other alpha-hydroxy acids, salicylic acid, Jessner’s peel, and trichloroacetic acid. 

Duration of treatment:

Triple therapy always has a limited duration of use, due to the steroid component. Results can then be maintained with the non-steroid creams.

It is recommended to cease triple therapy including mometasone after 4-8 weeks.

If the triple therapy contains fluocinolone as the steroid component (eg “Tri-Luma”), it is usually given for 8 – 12 weeks.

Triple therapy containing hydrocortisone as the steroid component (eg “Pigmanorm”) should be used for no more than 8-12 weeks at a time. 

Hydroquinone should not be used for more than 6 months at a time

Tretinoin is often used long term – in some cases for years.

Azelaic acid can be used for months or years.

These creams are all best applied at night.

Other, rarely used treatments:

Tranexamic acid:

This is a tablet that promotes blood clotting. It is most commonly used to control heavy periods. 

At 250mg dose, twice a day, this has been shown to help melasma. However, once stopped, relapse generally occurs.

There are risks of causing blood clots with this medication.

Topical forms of tranexamic acid, or micro-injections of this into the skin – have been used with success. 

Other possible oral treatments:

  • Glutahione
  • Polypodium leucotomoa

Skin lighteners other than hydroquinone:

Other skin lighteners, alone or in combinations, can be used in people who do not tolerate hydroquinone. 

There is some evidence for:

  • Kojic acid
  • Rucinol
  • Niacinamide
  • Cysteamine hydrochloride
  • Undecylenoyl phenylalanine

Summary of melasma treatment:

  • The most effective treatment regime for melasma is triple therapy – a cream containing hydroquinone, tretinoin and a steroid (hydrocortisone, fluocinolone or mometasone)
  • If combined with monthly glycolic acid peels, this treatment is more effective
  • These “triple therapy” creams can only be used temporarily, for 2-3 months at a time, as the steroid component of these creams can cause side effects with prolonged use. 
  • Hydroquinone and tretinoin can also be used without steroids, together or as single therapy.
  • Azelaic acid is a gentler (but less effective) alternative if triple therapy is not tolerated. It can be used in combination with tretinoin or hydroquinone. Alternatively, it can be used in between courses of triple therapy.
  • A high SPF sunblock is essential
  • Melasma is challenging to treat and will unfortunately frequently recur after being treated. 

Health and beauty spotlight: Weight loss and maintaining a healthy weight:

Body weight is determined by a simple formula; calories in vs calories out.

Calories in come from your food and drink.

Calories out are due to your basal (resting) metabolic rate, exercise, and muscle mass.

If you take more calories in than you “burn off” each day, you will gain weight

If you take fewer calories in than you burn off each day, you will lose weight.

In order to work out what these numbers are, you can count the number of calories you consume, and work out an estimate of the number of calories you would usually burn off each day.

You can either do these calculations and aim for your ideal number of calories per day in order to lose weight, OR practice mindful eating so that you naturally eat fewer calories per day without counting. 

I will explain both approaches here, and advise both together initially, then maintaining a healthy weight for life with mindful eating alone.

It’s all about the maths:

If you are overweight and wish to lose weight, first decide what is a healthy, achievable and sustainable weight for you and eat the number of calories that would maintain that weight.  

A good way to decide how many calories you should eat per day is to calculate what your base metabolic rate would be if you were your goal weight.

For example, if you are 80kg and you calculate your BMR to be 1600 calories, but your ideal weight is 60kg, calculate your BMR as if you were 60kg.

This will be a lower number.

This is because to maintain a higher weight your BMR is higher.

If say, your BMR at 60kg would be 1400 calories per day, you should aim for that number per day now.

Then you would lose weight as there is a calorie deficit between your current BMR and the amount you are eating.

In this way, weight will be lost gradually, and when you reach your goal weight of 60kg and stay eating 1400 calories per day, you should remain at that weight.

The amount of calories you now aim for should not be a “diet” – a better way of looking at it is that you are now eating the correct amount for your body at its ideal weight. 

You will lose weight if you eat the appropriate amount, as when you are overweight, your BMR is higher in order to maintain it. When you reach your goal weight, stay on the same amount of calories per day.

If you “go on a diet” by temporarily reducing calorie intake and then stop the diet and start eating too many calories again, you will always gain the weight back.

Occasionally, a calculated BMR may not be accurate, due to incorrect calculations or an unexpectedly fast or slow metabolism.

An even simpler way to lose weight by counting calories is to keep a food diary over a few weeks, to determine the average number of calories that you eat per day.

If you are overweight, you now know that this number is more than your body needs.

Therefore, reduce the number of calories you consume to fewer than this. Start by just reducing by 100-200 calories per day under your usual amount. If you gradually lose weight, you know that you are on the right track. 

Body mass index:

This is a weight-for-height index that categorises adults into underweight, healthy weight, overweight or obese. It is calculated by dividing your weight in kilograms by your height in metres squared. The ideal healthy BMI is between 19 and 25. Your risk of a number of health problems rises significantly from a BMI of 25 while anything over 30 is a serious health concern.

Healthy ranges for BMI may differ between population groups – the relationship between the measurements and the risk of weight-related health problems varies by sex, ethnicity and age. 

BMI may underestimate risk in Asian people, or overestimate risk in highly muscular people who can be healthy at a higher BMI threshold.

You can check your BMI at: https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/

Waist circumference:

This is another good check for healthy weight. If your weight is increased due to having a great deal of muscle rather than fat, your BMI could be raised when you are not in fact carrying too much fat.

In fit muscular people, even with their increased body weight due to muscle, the waist circumference should remain below 80cm for women and below 94cm for men, in order to be a healthy size. 

Reference: https://www.nhs.uk/common-health-questions/lifestyle/why-is-my-waist-size-important/

Base metabolic rate:

This is the minimum number of calories your body needs at rest to fuel its metabolic activity, for example to maintain functions such as heart beat, breathing and temperature.

Basal energy expenditure usually accounts for about 50-80 per cent of total energy needs.

Your total daily energy expenditure is made up of three components:

  • Basal energy expenditure
  • Energy needed for physical activity
  • Energy required to metabolise your food

Because basal metabolism is affected by factors such as body fat and hormones, illness or infections, medications, or fasting, the values predicted by BMR equations may overestimate (some say by up to 20 per cent) or underestimate the true value. However, they are sufficiently accurate in the majority of people to fall within about 10 per cent of the true value.

You can calculate your base metabolic rate (BMR) on https://www.diabetes.co.uk/bmr-calculator.html

Calories:

The number of calories required to gain or lose 1kg (2.2 pounds) = approximately 7500 calories

Therefore, if you were to eat 500 calories below your base metabolic rate every day (for example, your BMR is 1500, and you eat 1000 calories per day), in 15 days this equals 7500 calories. Therefore in 15 days in this scenario, you would lose around 1kg.

A healthy rate of weight loss is around ¼ to ½ a kilogram per week. (About a pound a week)

Risks of being overweight:

Being overweight increases your risk of dying early, and of suffering from many health problems, including:

  • High blood pressure
  • High cholesterol
  • Type 2 diabetes
  • Heart disease
  • Stroke
  • Joint problems
  • Gallbladder disease
  • Sleep and lung problems and
  • Some cancers (including prostate, bowel, and breast cancers).
  • Infertility in women
  • Erectile dysfunction in men

Abdominal body fat, the ‘apple shape’, is a higher health risk than the ‘pear shape’. Also, the relationship between weight and cardiovascular risk is continuous — the more you gain weight, the higher your risk. Also, if you are overweight you may not feel your best and this can have an effect on your energy levels, confidence and many parts of your life.

Benefits of losing weight:

Even losing 5-10 per cent of your bodyweight if you are overweight or obese can have a beneficial effect on your risk of heart disease and other conditions. 

How to lose weight if you need to:

In order to lose weight and keep it off, you need to eat fewer calories than you currently do, and continue to eat this amount rather than going back to the original amount when a “diet” is over.

You can either count calories in order to achieve this, or you can reduce the number of calories you eat but without counting them – see the section on Mindful eating for more information on this.

There are hundreds of diet programmes that have been advertised and come in and out of fashion over the years.

All of them work because the number of calories consumed is lower than usual.

Whether you try the cabbage soup diet, Atkins, paleo, meal replacement, dukan, Zone, ultra low fat, low GI, slim fast, weight watchers, or intermittent fasting such as 5:2, if you follow the diet correctly you are likely to lose weight, as they all involve eating fewer calories than you did before.

When you stop the diet, and go back to eating as you did before, you will gain the weight back again.

If you continue the diet for the rest of your life this will not happen. However very few people are able to continue one of these restrictive diets every day until they are in their 90s!

Therefore, it is best not to go on a “diet” or aim for rapid weight loss with any programme that you cannot sustain for life. Instead, calculate the correct number of calories that your body needs to be a healthy weight, and eat this every day.

You should then lose weight very slowly, reach your goal weight and most importantly, stay at it.

You will not have to cut out any particular food, have days when you feel starving, or agonise over what to order in a restaurant. You can live your normal life, eating your favourite foods when you feel hungry, just not exceeding the healthy number of calories for you.

Food diary:

To begin with, it is a good idea to get insight into how many calories you are consuming and how you can achieve the ideal amount.

Record your daily food intake and exercise. Studies have shown that this is the best way to ensure your weight-loss programme will succeed. 

Write down your food and drink each day. Calculate how many calories are in each thing you eat or drink.

Beware of labels that state calories per portion. There may be many “portions” in each packet.

The food label may alternatively say how many calories are in 100g of the food, so you need to calculate the number of calories for the weight of the food you are consuming.

Write down the number of calories in any non-water drinks you have as well

After completing a food diary in this way, you may be able to find what parts of your diet can be changed

Weigh yourself regularly, say every 1 or 2 weeks, at the same time of day, and record your progress. This has been shown to help in managing weight loss.

While keeping your food diary, if you “cheat”, write down what you have eaten and the calories, rather than deciding to give up and start eating sensibly again another day. The purpose of this exercise is to gain honest insight into your eating habits. 

A typical pattern of eating for an overweight person might be calorie deprivation followed by binge eating. Another common pattern is consistent slight overeating with slightly too large portion sizes. Finding out what your pattern is can help immensely to improve habits for the future. 

Portion sizes:

Typical portion sizes have doubled in 20 years; a major contributor to the ever-rising obesity rates in western countries.  

For example, many people eat five times the recommended serving of pasta in a typical meal

Almost any meal – even most starters – served at a restaurant /café / fast food outlet are a far larger portion size than recommended for a meal; we have lost awareness of what a normal, healthy portion of food should be.

We tend to eat more when there is a larger portion in front of us, whether or not we are still hungry.

Researchers at the University of New South Wales in Australia found that even when study participants had been given a lesson in mindful eating, when served a large portion of macaroni, they ate 69 calories MORE than those who were served smaller portions.

You should start by preparing meals for yourself with the recommended portion sizes of food. This may seem very small at first!

Eat slowly and chew each bite. If you feel hungry immediately after eating this meal, plan to wait an hour before getting more food – it can take time for your body to register that it is actually full.

There are many online resources for checking what a healthy portion size is for various foods.

Tips to avoid overeating:

  • Eat plenty of fruit and vegetables
  • Serve yourself the recommended portion sizes 
  • Avoid fast food/junk food
  • Avoid soft drinks
  • Think about your relationship with food; figure out if there are times when controlling food intake is hard. You may be eating for comfort, out of habit or absent-mindedness, or just because there’s food around. Find other ways of controlling stress, and break old habits.
  • Don’t try to starve yourself to lose weight, this will cause you to overeat due to feeling excessively hungry later. When you are genuinely hungry, EAT. 
  • Avoid too many snacks; don’t keep high fat or sugar treats in the house — have them when you are out, occasionally. Have the fridge stocked at all times with healthy options.
  • Look at your food portions — if you are in the habit of piling up your plate, try gradually easing back. Use smaller plates and bulkier food so the ‘eye’ is full, and eat slowly so the message that the stomach is full has time to reach the brain. Bulking up with fruit and vegetables gives essential fibre and helps stave off hunger.
  • Check drink portion sizes too. A typical glass of wine is equivalent to 2 standard drinks and alcohol adds almost as many calories as fat.
  • Don’t confuse thirst with hunger. Make sure you plenty drink of water; carrying a large water bottle with you in your daily routine will ensure you keep hydrated and stop you from eating unnecessarily when you are actually thirsty.
  • Avoid restrictive diets or trying to lose weight too rapidly; people who do this tend to gain more weight long term.
  • You could begin by aiming to stay at your current weight for the first few weeks, while gaining insight by keeping your food diary, rather than aiming to lose weight immediately and quickly. As most people who try crash diets end up gaining more weight afterwards, simply staying at the same weight and not gaining any more is an achievement in itself!
  • Aim to adopt these healthier eating habits, a more active lifestyle, and sensible portion sizes, as your lifestyle, rather than as a temporary diet.

Barriers to weight loss:

Some people find that they gain weight when on certain medications or due to certain health conditions. If you think this could be the case, speak to your doctor about how this could be managed.

However, it is important to note that fat is still coming from the food and drink you consume – certain medications “Make you gain weight”, however, this is because they increase your appetite and it is the excess food you consume that causes the weight gain. 

Some people feel that it is impossible to be a healthy weight when they are unable to exercise due to health conditions. However, there are plenty of people who do not exercise who are a healthy weight – they simply eat an appropriate number of calories per day for their body’s needs. 

Healthy foods:

While you can lose weight and keep it off by eating an appropriate number of calories per day, no matter what foods this is comprised of, it is also important for your health to have nutritious foods. 

If you are overweight, stopping overeating is a major step towards improving your health, and you might find that you naturally desire more nutritious foods when you are sticking to a healthy number of calories per day. 

  • A balanced diet consists of plenty of vegetables, fruit, legumes (e.g. lentils, beans, chickpeas) and wholegrains (including wholegrain breads, cereals, pasta, rice, couscous and other grain foods).
  • Unless you are vegetarian or vegan, also include low-fat milk and dairy products, lean meat, poultry, fish, eggs and nuts. The so-called “Mediterranean diet” is a good example of a balanced diet that has been shown to help in weight loss and also has a beneficial effect on heart health.
  • It is best to consumefew foods containing saturated fats. Also avoid reduced fat foods where the fat has been replaced with sugar or refined starches such as maltodextrins. Instead, choose moderate portions of foods containing unsaturated fats, such as olive oil, avocado and nuts. Cut off any visible fat from meat, eat less fried food, takeaways, snacks, cakes, pastries and biscuits, all of which are high in saturated fat.
  • Limit intake of sugars. Avoid sugar-sweetened drinks. These are high in calories, but don’t fill you up, and are associated with an increased risk of weight gain. Sweetened fruit juice, sports drinks, and sugar added to tea or coffee should also be avoided.
  • Drink plenty of water each day.
  • Limit alcohol intake – it has multiple harmful effects on health, and is low in nutrients and high in calories.
  • Read labels, looking for calorie content, saturated fat and ingredient listing (they are in order of prominence in the product). Beware of so-called ‘low-fat’ or ‘reduced-fat’ foods, as many are made palatable by adding lots of sugar or starches.

Exercise:

Any increase in physical activity is beneficial to health, and will burn calories.

The increased exercise will also reduce your risk of type 2 diabetes and bowel cancer.

You can start slowly, andwork up to 150 to 300 minutes of moderate (where you can still hold a conversation, e.g. a brisk walk) of exercise per week – this equates to about 25-50 minutes most days of the week. Or, 75-150 minutes per week of vigorous, higher intensity activity. 

It is best to do exercise that you enjoy, that doesn’t burn a huge number of calories, than something very intense that you feel you “should” do, but don’t enjoy, as you will not sustain this forever. 

Anything that gets you moving is better than nothing; if you can’t schedule a block of time for exercise, try shorter bursts of activity, such as walking around the block at lunch time, or after dinner every day.

Try different sports or forms of exercise to find what you enjoy the most, and if you can do an activity with friends or family, you are even more likely to stick to it. 

In one study, the average number of steps taken per day by women between the age of 18 and 50 was just over 5000. For men the average was 6000.

People who were overweight took 1500-2000 fewer steps per day than the people who were a healthy weight.

Therefore, the difference between being slim and overweight was only the difference of walking a few blocks!

If you feel that exercise is a case of “all or nothing”, remember this – one walk per day – if part of your usual routine – can make a big difference over time. 

Strength training:

Strength training and muscle-strengthening activities increase your metabolism. Muscle burns more calories at rest than fat does. 

Each day, a kilogram of muscle burns over 10 times as much energy as a kilogram of fat just to maintain itself. Therefore, having extra kilos of muscle in your body will automatically mean you burn off more energy from food. 

Also, the stronger you are, the more likely you are to exercise, and you’ll look trimmer because you are toned.

Other benefits of building muscle mass include reducing the risk of health problems including type 2 diabetes.

Weight loss programmes:

There are many weight-loss programmes, personal trainers, gym programmes, online weight-loss programmes, apps, and self-help books available. 

If you decide to try one of these, choose a programme that teaches you how to make permanent changes in eating habits and levels of physical activity so you take weight off AND keep it off. 

If it offers a quick fix or recommends removing whole food groups, this is very unlikely to cause long term weight loss, and it is common to gain more weight than you had originally after stopping it.

If choosing a weight-loss programme, ask yourself these questions:

  • Is the person/staff qualified to offer advice?
  • Does the programme include lifestyle changes in food intake AND physical activity?
  • Does the programme promote a slow, gradual weight loss?
  • Is there a maintenance plan included and does it teach you how to get through difficult times?
  • Are the food choices flexible, suitable and affordable?
  • Are there hidden costs (special foods/supplements)?
  • What is the success rate of the programme in long-termweight loss?

The most important question to ask, is do you see yourself following this programme forever – imagine yourself in 10 or 20 years time – are you still doing this programme? Are you enjoying the food you are eating? If there anything you had to cut out that you crave? Are you enjoying the exercise?

If you do not see yourself doing this in 10 years time, don’t bother starting it – dieting temporarily only ever causes temporary weight loss before it is gained back again (usually ending up at a higher weight than before).

Mostpills, potions and herbs, passive machines (such as vibrating or electric shock machines) and rub-on creams do not help you lose weight. There is also little evidence for complementary medicines or nutritional supplements as an aid to weight loss.

If these products state that they caused weight loss in their clients, it will be because their clients ate fewer calories per day or exercised more as well as taking that supplement.

Weight loss programmes will try to justify themselves by making weight loss seem more complicated than it has to be. Remember, if a diet works, it is invariably because the people on it eat fewer calories than they did before, not because of a special trick which is specific to that diet or programme. 

Mindful eating:

The following is a summary of Paul McKennas brilliant book, “I can make you thin”.

He advises 4 golden rules, for people to eat their favourite foods, without starving themselves, lose weight and keep it off.

He does not advise counting calories, as I have, but instead to eat mindfully so that you naturally eat fewer calories than before. 

I usually advise initially keeping a food diary and counting calories as well as mindful eating, as this gives good insight and helps to start a more positive lifestyle, and then maintaining results by continuing mindful eating for life.

 

Paul McKenna’s 4 Golden rules:

  • When you are hungry – EAT.  Do not go on a “diet”, do not starve yourself, do not obsess about foodand feel guilty for eating. Food is there to be enjoyed and give us nutrition!
  • Eat only what you want, not what you think you should. Do not eat diet ready meals just because the packet says they are low in calories (unless you happen to find them delicious!)
  • Eat consciously and enjoy every mouthful. Free yourself from the guilt of eating – enjoy it! Slow your eating speed down to about a quarter of usual. Savour every bite like a gourmet. When you have got the nutrition you need, you will likely stop enjoying each bite as much. 
  • Stop when you even think you are full. When you eat slowly and mindfully, you will notice when you start to feel full. The first sign is that each bite is less delicious – as you have had the nutrition you need.STOP eating when you suspect you might be full. Throw away the rest of the food or save it for later if possible. DO NOT eat everything on your plate. 

This advice is based on the fact that so many of us overeat without realising it – due to a large portion being put in front of us, out of habit, being bored, feeling excessively hungry due to yet another restrictive diet, or simply because we are not paying attention to our body telling us it is full.

If we eat slowly, and mindfully, savouring every mouthful, and pay attention to when we start to feel full, we are likely to eat only what we need and not too much. 

If overweight, this approach will cause weight loss and then weight should be maintained at the healthy weight which is achieved. 

In order for this to work, you must get into the habit of leaving food on your plate; the principle is that you eat what you want, when you want, but very slowly and STOP as soon as you feel full.

By eating everything on your plate, you are letting someone else (or you from earlier that day!) determine your calorie intake and therefore weight. Get comfortable with leaving food. It may feel strange initially to throw away 1/3rdof the sandwich you brought to work for lunch, but it is better to “waste” food by discarding it, than waste it by turning it into fat on your body.

As you get accustomed to eating the correct amount for your body, you will start to serve yourself smaller portions to begin with and therefore waste less. 

You will not have to count calories with this approach, but will eat significantly less than before, without counting them.

Summary:

  • If you are overweight, this means that you must be taking in more calories than your body needs.
  • You can calculate your base metabolic rate as if you were your ideal weight – the number of calories per day that your body needs to be healthy – and aim for that number.
  • Keeping a food diary including calories can help you gain insight into what you are eating. If you choose to do this, keep the diary for several weeks in order to gain an understanding and encourage you to be more mindful of what you are eating. Don’t just keep the diary on “good” days!
  • Eat whatever foods you like (just stop when you are full, or approaching your daily calorie limit), but try to include lots of fruit and vegetables and only rarely have obviously unhealthy food such as fried or oily foods, or sweets.
  • Drink plenty of water – it helps to invest in a personalised water bottle and keep it with you.
  • Mindful eating means eating slowly and savouring every bite. STOP eating when you stop enjoying your food as much, and suspect that you are full, even if there is a lot of food left on the plate or half of a sandwich left.
  • Do not follow “diets” – going on a diet implies that you will come off it one day. Instead, decide to eat the right amount for your body – for life.
  • A “diet” also implies restriction, and hardship. With mindful eating and being more kind to yourself, you can enjoy food and still achieve a healthy weight. Get rid of the calorie restricted ready meals that taste like cardboard, and instead eat foods that you find nutritious and delicious, savouring every bite, and stopping when you are full.
  • Exercise more – something that you enjoy, can fit in to your life, and that you are likely to KEEP DOING because you actually want to.
  • The main thing is to enjoy food, and enjoy exercise. Try not to see either as a sin or a punishment, they are both things that we need to keep healthy and happy. 

Skin concern spotlight: Acne

What is acne?

Acne is a disorder of the pilosebaceous unit – the hair follicle and oil gland

It typically affects the face (99% of people affected with acne), chest (15%), and back (60%).

How common is acne?

Acne is extremely common: almost every adolescent will experience acne to some degree.

It can persist beyond the teenage years or recur at a later date. The majority of cases resolve by age 25. 

15% of women and 5% of men continue to have acne during adulthood.

What causes Acne?

Acne is due to excess sebum combined with excess desquamated epithelial cells, which then cause follicular plugging and distension.

(Sebum is the light yellow, oily substance that is secreted by the sebaceous glands that help keep the skin and hair moisturized. Sebum is made up of triglycerides, free fatty acids, wax esters, squalene, cholesterol esters, and cholesterol)

The distended follicle is called a microcomedo.

The microcomedo expands in size to form either an open (blackhead) or closed (whitehead) comedone.

A bacteria called Propionibacterium acnes proliferates in the follicle. 

This causes an inflammatory reaction which weakens the wall of the follicle. 

Eventually the wall ruptures, and the sebum-keratin mixture leaks into the dermis, provoking an immunological reaction.

As a result, inflammatory lesions develop – papules, pustules, nodules and cysts.

Scarring can occur as a result of recurrent rupture and re-epithelialisation of cysts.

What are the risk factors for significant acne?

Genetics seem to play a role.

A positive family history means that significant acne is more likely

Hormones affect acne:

Sebum production is androgen (male sex hormone) driven. Note – females also have male sex hormones, just to a much lower degree than men. 

The sebaceous glands of people with acne may have an increased response to normal levels of plasma androgens.

Acne is often worse in women with PCOS (who often have higher testosterone levels than other women) and during the pre-menstrual phase.

Any condition with abnormal androgen levels can result in acne, such as testosterone therapy, anabolic steroid misuse or Cushing’s disease.

Progestogenic contraceptives can reduce a protein called sex hormone binding globulin (SHBG usually lowers testosterone levels) and therefore can make acne worse. 

The vast majority of patients do not need any investigations, but occasionally blood tests are recommended – for example testosterone levels can be checked if PCOS is suspected.

No specific foods are implicated.

There is some evidence that dairy-rich or high GI diets may be associated with acne, although other studies show no link.

Obesity may increase the risk of acne, as obesity can affect the hormone profile. 

Smoking is associated with more severe acne.

Medications that can aggravate acne include lithium, ciclosporin, carbamazepine and azathioprine.

Stress: There have been small studies suggesting a link between severity of acne and exam stress.

Classification of acne:

Acne can be categorised as mild, moderate and severe:

Mild – total lesion count <30. Mainly non-inflammatory comedones. Usually confined to the face

Moderate – mixture of non-inflammatory comedones and inflammatory papules and pustules. May extend to the shoulders and back.

Severe – nodules and cysts (nodulocystic acne), inflammatory papules and pustules. 

Acne conglobate is an uncommon form of severe acne where there are abscesses.

Severe acne is defined as >5 cysts, or total comedone count >100, or inflammatory lesion count >50, or total lesion count >125

Acne general / lifestyle advice:

To reduce acne, it is best to avoid smoking and follow a healthy diet. 

Excessive facial cleansing can make symptoms worse by exacerbating inflammation, particularly astringent or exfoliative products. 

Only a gentle cleanser should be used.

Avoid oily cosmetics; use water-based products instead. 

Avoid picking or squeezing the spots – this will worsen inflammation and can introduce infection. 

Treatment options:

Inflammatory acne lesions take 4-8 weeks to completely heal, which is in line with the natural cell turnover of the epidermis. 

This is why there is a delay in onset of benefit when using any new acne treatment.

Treatments can be either topical (applied to the skin), or systemic (taken in pill form).

Topical options:

  • Retinoids – for example Adapalene
  • Antibiotics – clarithromycin or erythromycin 
  • Benzoyl peroxide (BPO) – This is the only over the counter (not requiring a prescription) ingredient with evidence of efficacy for acne. It can be used in combination with either a retinoid or antibiotic. 
  • Azelaic acid 20% – can be tried if the above do not help.

Systemic options:

  • The combined oral contraceptive pill 
  • Antibiotics – tetracyclines, erythromycin or trimethoprim 
  • Androgen receptor blockers – e.g. spironolactone, cyproterone acetate, flutamide (prescribed in secondary care only – i.e. by a dermatologist rather than a GP)
  • Isotretinoin (secondary care only)

Topical retinoids:

These are vitamin A derivatives.

They are anti-inflammatory, and comedolytic (reduce comedones) 

They can also reduce post-inflammatory hyperpigmentation in darker skin

They can be irritant; side effects can include transient redness and skin peeling. 

If this is troublesome, the frequency or strength can be reduced.

Adapalene 0.1%  – 0.3% is usually the best tolerated retinoid for acne. It is the usual first line treatment.

One brand of adapalene is “Differin”.

Treatment may be needed for several months and should be continued until no new lesions develop. 

Retinoids cannot be used by pregnant women.

Topical antibiotics:

Examples are clindamycin and erythromycin.

Mode of action – antimicrobial, anti-inflammatory

These are usually a second line treatment, if BPO or topical retinoids have failed to adequately control symptoms.

Rather than stopping BPO or retinoids, topical antibiotics are ADDED to the treatment. 

The risk of developing antibiotic resistance is a concern. To reduce this risk, a topical antibiotic SHOULD be used alongside another topical treatment such as BPO, but NOT be used at the same time as systemic antibiotics. 

It is advisable to limit the duration of topical antibiotic use to 12 weeks if possible.

Benzoyl peroxide:

This is available without a prescription.

Mode of action – comedolytic, antimicrobial, anti-inflammatory

This kills bacteria and helps prevent antibiotic resistance. It also has more of an anti-inflammatory effect compared to retinoids.

It is available of strengths from 2.5% to 10%. A usual starting concentration is 5%.

Stinging, peeling, and redness can happen and are worse if the skin is especially greasy. Side effects are greater at higher strengths.

BPO can be used every other day and then built up to use every day. 

Bleaching of clothes, hair and bedding can occur. 

BPO causes retinoids other than adapalene to become unstable.

Retinoids and BPO can be applied separately – one in the morning and one at night.

Both can be irritant however so this may not be tolerated.

These treatments will cause skin redness when first used but this should settle after about 2 weeks.

Azelaic acid 20%:

Mode of action – comedolytic, antimicrobial, anti-inflammatory

This has a weaker evidence base for efficacy than other topical agents – so is a second line treatment. 

It is less irritating than retinoids or BPO and hence better tolerated. It is generally used as an alternative for those who cannot tolerate other treatments.

It can be used in all severities of acne.

In some people it can cause temporary hypopigmentation (lighter skin), especially in those with darker skin. It can transiently lighten skin and this may be seen as a benefit in those with post-inflammatory hyperpigmentation

Systemic treatments: Oral Antibiotics:

The first line systemic treatment is usually an antibiotic in the tetracycline family, such as lymecycline.

Tetracyclines have less resistance problems and more anti-inflammatory properties than other Abs.

All tetracyclines and contraindicated in pregnancy, breastfeeding and children under 12.

Tetracyclines can cause dyspepsia and sensitivity to light.

If tetracyclines cannot be used, a macrolide such as erythromycin is the next choice. There are higher levels of bacterial resistance to this.

Oral antibiotics should be used in conjunction with either topical retinoids or BPO to reduce the risk of resistance developing. 

They should not be used concurrently with topical antibiotics.

Generally, maximum benefit will be achieved by 3 months. However, some people respond more slowly so they can sometimes be continued for 6 months in total.

There is little value in continuing beyond this due to the increased risk of resistance.

Further courses of the same antibiotic may be needed in the future. 

Systemic treatments: Oral hormonal treatments:

Mode of action: Reduced androgenic (male sex hormone) effect on follicles.

A standard contraceptive pill can be used for acne. It can take up to 6 months to help.

If a standard pill does not help, Co-cyprindiol (eg Dianette) contraceptive pill can be used. 

This has more of an effect on acne as it contains the anti-androgen hormone cyproterone acetate.

It also helps hirsuitism (excess hair, which can occur with PCOS)

It is not the first choice, as it has a greater risk of causing blood clots than other forms of the contraceptive pill. 

It should be ceased 3-4 menstrual cycles after the acne has resolved; and maintenance therapy can then be with a standard contraceptive pill. 

Systemic treatments: Oral isotretinoin (Roaccutane):

Mode of action: Reduced sebum production, anti-inflammatory.

Isotretinoin is only initiated by specialists, due to the pre-treatment counselling and monitoring required.

It is highly effective, but has a significant side effect burden. Redness and dry skin are very common. More rarely, colitis, pancreatitis, hepatitis, or high cholesterol can occur.

It can cause birth defects, and so reliable contraception is essential during use and for 1 month afterwards.

Blood tests are required before and during treatment

It can also affect vision, and airline pilots will not be able to continue their job while taking isotretinoin.  

Acne treatment in pregnancy:

As retinoids and some antibiotics are unsafe in pregnancy, a typical treatment regime for a pregnant woman involves BPO and topical erythromycin.

Key points of acne treatment:

  • Topical retinoids such as Adapalene 0.1 – 0.3% are first line treatment, but benzoyl peroxide 2.5% – 10% can be used instead, and this doesn’t need a prescription.
  • Azelaic acid 20% is less effective, but causes less irritation than retinoids or BPO so is a gentler alternative to them.
  • Topical antibiotics are the next step up – they can be used in combination with a retinoid or BPO
  • Topical and oral antibiotics should not be used together.
  • The contraceptive pill can help acne in women. Anti-androgen pills are most effective but have greater risks that the standard pill.
  • Isotretinoin (Roaccutane) is very effective, but initiated by specialists only due to its side effects and risks. 

Skincare spotlight: Retinoids (Vitamin A):

Retinoids consist of natural and synthetic derivatives of vitamin A that can be found in both prescription medications and over the counter cosmeceuticals. 

Benefits:

Retinoic acid increases cell turnover and stimulates collagen and elastin production.

Therefore, it can treat pigmentation, cystic acne and wrinkles.

RA is thought to reduce mottled hyperpigmentation by enhancing epidermal cell turnover.

It reduces fine lines and wrinkles by increasing the capacity of the epidermis to hold water through stimulation of glycosaminoglycan (GAG) synthesis, and by stimulating collagen synthesis through increases in transforming growth factor (TGF-beta) and procollagen.

RA reduces skin roughness by modulating the expression of genes involved in cellular differentiation and proliferation, hence promoting epidermal cell turnover.

Surface roughness, mottled hyperpigmentation, and fine wrinkles demonstrate the most significant improvement with RA therapy.

Forms of retinoids:

The topical cosmeceutical retinoids include many different forms of vitamin A: Retinyl esters, Retinol, Retinaldehyde, and the group of Oxoretinoids.

Retinoic acid (RA) is the biologically active form of vitamin A.

It has been extensively studied and used as an effective topical treatment for photoaging, acne, and numerous other dermatological disorders. 

Retinoic acid can, however, be irritating to the skin, limiting its use in some patients. 

Retinol (ROL) and retinaldehyde (RAL) are gentler yet still effective topical alternatives to Retinoic acid (RA).

In the skin, ROL is oxidized into RAL, which in turn needs to be oxidized into RA before it will be biologically active.

The other cosmeceutical retinoids, retinyl palmitate and retinyl-acetate, are retinoid esters and are NOT considered effective against photoaging.

While ROL and RAL containing cosmeceuticals have not been shown to produce the magnitude of clinical results obtained with the prescription products that are approved and used to treat photoaging (such as tretinoin, tazarotene), many consumers are pleased with their cosmetic results.

Cosmeceutical retinols – which need to be converted into retinoic acid before the skin can use it – use around 10 times more retinol content than prescription retinol.

When to start:

It is best to start using retinoids at age mid-20s, when the first signs of ageing are about to occur. 

Side effects:

Any Retinoid products can cause dryness, redness and flaking of the skin. These side effects usually last for the first 2 weeks of use and then resolve.

Side effects can be minimised by using the product just once or twice a week, gradually increasing frequency as tolerated.

A common way to use retinoids is for 3 months, then with a 3 month break. This is due to research suggesting that this is just as effective as continuous use; cell turnover is no longer increased after 3 months of use.

Once skin cells have adapted to the strength of the retinoid being applied, any irritation generally stops. Skin is unlikely to flare up again unless the retinoid is switched to a stronger version.

When to apply:

Retinoid products are thought to cause sensitivity to UV rays, although there is conflicting evidence on this.

They are known to break down in sunlight, which is why they will not come in a clear bottle, and why they should be applied at night rather than in the morning.

A good sunblock is essential regardless of retinol use, to reduce the risk of skin cancer and photoageing.

Who should not use retinoids:

Rosacea, eczema or psoriasis can be worsened by retinoids, as they can make the skin more vascular.

It can be unsuitable for sensitive skin, and can cause worsening inflammation if the skin is prone to this.

It can be unsuitable for those with dry skin, as retinoids are drying.

What strength to use:

This depends on the product – and where on the pathway it is in the process of being converted to the active molecule retinoic acid. 

The below list reads from weakest to strongest product: 

Retinyl palmitate has to be converted 3 times within the skin to become active – to retinol, then retinaldehyde, then retinoic acid.

It is the lightest and most gentle form of vitamin A.

It is typically used for people who cannot tolerate retinol due to sensitive skin. 

Retinol is the next step up – and is the over-the-counter standard. 

There are a lot of over the counter products with a low percentage of retinol – from 0.01 to 0.03%.

Moderate strength products contain 0.1% to 0.3%

Higher strength would be 0.5% to 2% retinol. 

Retinaldehyde is the next step after retinol – one step closer to the active molecule. It is the closest form to the active molecule available without a prescription. 

A typical strength of retinaldehyde is 0.1%.

Tretinoin – is prescription only. It is also known as all-trans-retinoic-acid – are typically the mildest form of prescription retinoids. This is the active molecule.

The weakest tretinoin cream is 0.005% 

Moderate strength would be 0.025 – 0.05%

The strongest available is usually 0.1%. 

Synthetic retinoids: Developed to treat acne, but also having anti-ageing effects: 

Isotretinoin (13-cis-retinoic acid). Trade name “Accutane” or “Roaccutane”.

Adapalene – “Differin” – this is a newer generation of synthetic retinoid that was developed to treat acne. It is more chemically stable than other retinoids.

Tazarotene – another new retinoid developed for acne, this binds to fewer receptors than other forms, making it less irritating to the skin.


Encapsulated retinoids:

Encapsulation is a wall surrounding an ingredient.

This can be composed of polymers, phospholipids, cyclodextrin, some surfactant type materials, waxes or combinations.

Encapsulation is used to delay the release, increase absorption, prevent penetration (keep it on top of the skin), stabilise or protect the ingredient from interacting with other molecules in the formula.

If encapsulated, the retinoid is housed in a carrier system, to protect its integrity and improve its ability to penetrate the skin effectively. Apolymer encapsulated retinol enhances stability and decreases irritation.

The encapsulated retinol is immobilised to drip feed Vitamin A into the skin over hours. This timed delivery to the skin results in less irritation.

What can be combined with Retinoids:

Niacinamide:Some formulations combine a retinoid with niacinamide (a form of vitamin B3). Niacinamide boosts ceramide production – making skin more robust and tolerant of irritants – and has anti-inflammatory properties. This means that the retinol may not cause as much irritation if combined with this. The retinol induced initial peeling (a sign that it is working) will not be affected however.

Vitamin E (Tocopherol):as this is moisturising, anti-inflammatory, and anti-oxidant, it can help to soothe the skin when combined with a retinoid. 

Hyaluronic acid:This is a hydrating agent and so can negate the drying effect of retinoids. 

Ceramides:These are lipids (fats) that are found naturally in the skin. 

They soothe the skin and boost the efficacy of other skincare ingredients.

Ceramides can be found in certain retinoid skincare products. 

Peptides:These are short chains of amino acids – i.e. fragments of proteins. They can have anti-oxidant and anti-inflammatory properties. 

Azelaic acid:this is a naturally occurring acid found in grains such as barley, wheat and rye. It has anti-microbial and anti-inflammatory properties.

It can reduce skin blemishes and pigmentation.

Phenols (eg resveratrol):These have antioxidant and anti-inflammatory properties. 

Omega-3 fatty acids:These are good moisturisers which can help with the drying effects f retinoids

Colloidal oatmeal:This is soothing and moisturising, so works well with skin care products such as retinoids that can irritate the skin. 

What can sometimes be used with retinoids:

AHAs and BHAs:Retinol combined with either an Alpha hydroxy acid or beta hydroxy acid can improve the results obtained from both ingredients, and further fade hyperpigmentation in the skin.

Using both or all three together can however increase irritation to the skin.

Therefore, a typical anti-ageing skincare routine might be a daily retinoid, with an acid weekly or monthly to exfoliate.

Lactic acid or Glycolic acid:  These are both members of the Alpha hydroxy acid (AHA) family.

They are moisturising forms of AHA. 

Glycolic is derived from sugar cane and lactic acid from milk, but they both work in the same way.

They exfoliate the skin gently but moisturise as well.

Vitamin C: as this is unstable, layering it with other products can render it useless. Vitamin C can be used in the morning and retinol at night, but they shouldn’t be used at the same time.  

If the retinoid formula is acidic, then the vitamin C will not be destabilised. Retinoids are not harmed by an acidic environment so a combination product is possible, but ONLY at the correct pH.

What should NOT be used with retinoids:

Benzoyl peroxide(BPO) for acne: 

Using both creams together can deactivate the retinoid.  

BPO is a very drying product, and can cause redness and irritation. 

BPO and retinoid products can be used separately if needed, for example BPO in the morning and retinol at night, but this may not be tolerated due to these increased side effects.

How long until results are seen:

It takes an average of 12 weeks for retinoic acid to produce noticeable changes in the skin. 

The stronger the formulation, and the more frequently it is used, the quicker results will be seen.

Summary:

  • Retinoids are an evidence based anti-aging ingredient.
  • Retinoic acid increases cell turnover and stimulates collagen and elastin production. Therefore, it can treat pigmentation, cystic acne and wrinkles.
  • Irritation, dryness, redness and peeling can occur, particularly in the first 2-3 weeks.
  • It takes around 12 weeks for noticeable skin benefits to be seen
  • Retinol is converted to retinaldehyde, which is then converted to retinoic acid – the active molecule. A product is stronger if it is further along this chain.
  • Each of these is available in different strengths.
  • It is sensible to start with a low potency product, building up gradually. 
  • Retinoid products should be applied at night
  • Formulations can contain retinoids and other skin care ingredients, particularly soothing or moisturising ones.

Spotlight on: Sunscreen / Sunblock: The most important anti-ageing skincare tool

Sunblock or sunscreen are very important basic skin care products, to protect the skin from UV damage.

They are the first and best line of defence against premature ageing from the sun.

Based on their mechanism of action, sunscreens are also traditionally divided into inorganic (physical) blockers and organic (chemical) absorbers.

SunBLOCK refers to physical blockers, and sunSCREEN refers to chemical absorbers.

SunSCREEN:

Sunscreen chemical absorbers contain substances which are capable of absorbing UV radiation of a specific range of wavelength based on their chemical structure. 

These include derivatives of anthranilates, benzophenones, camphor, cinnamates, dibenzoylmethanes, para-aminobenzoates, and salicylates.

Broad spectrum filters used in sunscreen have a higher level of absorption. The organic filter molecules absorb UV energy and transform to higher energy state from the ground state. Excess energy is released via isomerization and heat release resulting in the emission of higher wavelengths or relaxation.

These filters can be photostable, photounstable, or photoreactive. 

Photounstable filters are the molecules which undergo degradation or change in their chemical structure on the absorption of UV radiation. Hence, these cannot absorb UV energy on subsequent exposure.

Photostable filters are the molecules which dissipate the absorbed energy to the surroundings in the form of heat. These filters efficiently continue to absorb UV energy.

Photoreactive filters jump to their excited state on irradiation with UV. Once in their excited state, they interact with other molecules in their surrounding including the ingredients of sunscreen, skin lipids and proteins. 

This interaction results in the production of reactive species, resulting in untoward biological effects. 

Oxybenzone and Octinoxate:

These are chemical sunscreen filters.

Oxybenzone is the most common UV filter used in products worldwide. It is used in almost every foundation and day cream that claims to have an SPF 15.

These chemical filters penetrate into the skin, and absorb the UV rays. The chemical filter will break down within 2 hours by 95%, which is why chemical sunscreens need to be reapplied every 2 hours when in the sun. 

When they break down, they increase reactive oxygen species (ROS). This can cause DNA damage which leads to ageing. 

Oxybenzone penetrates into the blood stream, lymph system and has been found in breast milk.

Octinoxate absorbs through the skin in significant amounts; A study found Octinoxate in the urine of 97% of americans.

It is associated with photoallergic reactions, and theoretically, endocrine (hormone) disruption can occur.

Ingredients such as phthalates and parabens are also suspected endocrine disruptors – these are found in many sunscreens and other cosmetic products and soaps.

While the systemic absorption of these products and their possible adverse effects are concerns, there is no evidence that they do cause harm in humans; concerns are theoretical only.

It is likely that these ingredients could cause harm if consumed in vast quantities, but not in the amounts we are exposed to by wearing sunscreen. 

Oxybenzone can cause endocrine disruption in marine life – including causing sex change in fish.

For this reason, some tourist beaches have policies that visitors must exchange their usual sunscreen for a more biodegradable one.

SunBLOCK:

Inorganic, physical blockers include zinc oxide, titanium dioxide, iron oxide, red veterinary petrolatum, kaolin, and calamine. 

These filters block UVB and UVA rays through scattering and reflection. 

The larger metal oxide particles tend to diffuse the light from the visible range of the spectrum leaving an undesirable whitish appearance on the skin. 

This whitening effect and opaque nature are some disadvantages of these filters, which can be minimised to some extent by the use of ultrafine particles. 

Skincare ingredient spotlight: Zinc Oxide:

Zinc oxide and Titanium dioxide are physical filters used in physical sunscreens.

Zinc and Titanium do not absorb into the skin, breakdown or cause endocrine disruption.

They sit on top of the skin reflecting and absorbing UVR like mirrors, and offer broad spectrum protection.

A nanometre is one billionth of a metre. This helps to measure the wavelength of light.

UV rays from the sun range from 290 to 400 nanometers. 

The longer the wavelength, the deeper it can penetrate into the epidermis or dermis, causing free radical damage. 

Zinc Oxide blocks rays in this entire range, unlike most chemical sunscreens.

Looking at this evidence, physical blockers are far more effective than chemical.

However, no sunscreen or sunblock will be effective if not enough is used, or if it is not used regularly.

How much to apply:

Its advised that we apply 2mg per square cm to our skin. This is around 6 full teaspoons (about 36 grams) to cover the entire body (1/2 a teaspoon for the face) which is the amount used when determining a products sun protection factor. 

Studies have found that most people apply less than half of the amount required to provide the SPF level of protection indicated on the packaging. 

It should be applied at least 15-30 minutes before going outside.

What SPF to use:

The higher the better. An SPF of at least 30 is advisable, and this should be a broad spectrum sunscreen – protecting against UVA and UVB rays.

Vitamin D:

400 units (10 micrograms) of vitamin D is the usual daily requirement. 

Vitamin D can be obtained from natural food sources, fortified foods, and supplements. Sunlight also helps our skin to produce vitamin D. 

It can be difficult to get enough vitamin D from diet alone, which is why deficiency is very common in people who live in countries without much sunlight.

Vitamin D deficiency can cause health issues, so it is important to get enough through supplements or sunlight. 

As UV rays can cause skin cancer and premature ageing of the skin, it is best to wear sunblock to the always exposed areas – face neck and hands – every day, and avoid heavy tanning or burning of other areas.

Recommendations:

  1. Look for zinc oxide on the ingredients list – as this is the most effective physical blocker. 
  2. Apply sunblock liberally to all exposed skin, 30 minutes before going outside, 365 days of the year
  3. Wait a few minutes for the sunblock to set before applying makeup
  4. Invest in a good broad spectrum, high SPF sunblock to use.
  5. Wear water resistant sunblock if swimming, and reapply regularly on hot days, if swimming or exercising outside.
  6. Wear wide brimmed hats when sunny outside.
  7. Don’t forget hands – reapply sunblock to them after washing them – to keep them looking young too!
  8. Most people will benefit from a daily vitamin D supplement. 400 units is the usual daily requirement for an adult, but daily supplements of 800-1000 units can be safely taken. 

Skincare spotlight: Vitamin C:

Vitamin C is an antioxidant, enables collagen synthesis, and reduces inflammatory pathways. It also inhibits melanogenesis – i.e. prevents age spots and hyperpigmentation. 

All of this can have a big impact on reducing the signs of skin ageing. 

Reducing hyperpigmentation and age spots:

Vitamin C does not absorb UV light but exerts an UV protective effect by neutralizing free radicals – this is its antioxidant effect.

It works as a depigmenting agent by interacting with copper ions at the tyrosinase-active site which inhibits action of the enzyme tyrosinase, thereby decreasing melanin formation.

Collagen production:

Vitamin C is also essential for collagen biosynthesis. Clinical studies have shown that the topical use increases collagen production in young as well as aged human skin.

Vitamin C also inhibits certain pro-inflammatory cytokines, and therefore has potential anti-inflammatory properties.

Therefore, vitamin C is found in many skincare products – but how can you tell if a product has significant amounts of active vitamin C, or if it is just some orange extract and a marketing claim?

To answer this, we need to consider 4 things:
1: What form of Vitamin C is in the product? L’Ascorbic acidis more bioavailable that BV-OSC.

2: What percentage of this vitamin C is in the product? At least 10-15%is required before it will be enough for collagen production.

3: Is the formulation still active? Vitamin C oxidises and becomes inactive, turning brown, when exposed to sunlight.

4: What else is in the product? When combined with vitamin E or Ferulic acid as well, vitamin C can be more effective.

Question 1: What form of Vitamin C is in the product?

L’Ascorbic acid:

  • Bioavailable
  • Water soluble
  • Antioxidant 
  • Stimulates collagen

Tetrahexyldecyl ascorbate (BV-OSC), Ascorbyl glucoside, Acsorbyl-6-palmitate, Magnesiun ascorbyl phosphate, and Aminopropyl ascorbyl phosphate:

  • Have to convert to L’ascorbic acid
  • Oil soluble
  • Antioxidant

Tetrahexyldecyl ascorbate (BV-OSC), Ascorbyl glucoside, Acsorbyl-6-palmitate, Magnesiun ascorbyl phosphate, and Aminopropyl ascorbyl phosphate are oil soluble, so offers hydration and antioxidant protection in the upper layers of skin.

They have to be converted into L’Ascorbic acid before the body can use it to stimulate collagen.

If a product claims to have 15% Vitamin C but this is BV-OSC, that will offer antioxidant protection. However, to stimulate collagen production, the BV-OSC needs to be converted to L’Ascorbic acid first. This will occur on the skin to some degree.

The amount of the 15% BV-OSC that is then converted to L’Ascorbic acid depends on the health, age and skin condition of the person.

The amount converted may not be enough for collagen synthesis. 

Therefore, even a product that is “15% vitamin C” may not be optimum for anti-ageing.

Question 2: What percentage of Vitamin C is in the product?

10-15% of L’Ascorbic acid is needed for a product to have anti-ageing properties

The efficacy of the Vit. C serum is proportional to the concentration, but only up to 20%.

Beyond 20%, there is not a greater anti-ageing effect, and concentrations above this have a higher risk of causing skin irritation. 

Question 3: Is the product still active?

L’Ascorbic acid is water soluble and very unstable.

On exposure to light, L’Ascorbic acid gets oxidized to the yellow Dehydro Ascorbic Acid. 

As a water soluble and charged molecule. L’Ascorbic acid is repelled by the skin.

For cosmetic products, the stability of the product can be increased by lowering the pH (making it more acidic). A pH of less than 3.5 is ideal. 

The skins normal pH is 5.4, so many skin products aim to be closer to this pH, which is problematic for vitamin C.

At this pH, the ionic charge on the molecule is removed and it is transported well across the stratum corneum of the skin. 

L’Ascorbic acid oxidises and becomes inactive, turning brown, when exposed to sunlight. Using an oxidised product is not going to be beneficial for the skin.

A pH below 4, an airless tube and packaging that is not transparent is necessary. If this is not the case, there is no value in applying L’Ascorbic acid to the skin.

One way to stabilise L’Ascorbic acid is by adding a phosphate group. BV OSC is a stabilised form of L’Ascobic acid. 

Examples include:

  • Ascorbyl glucoside
  • Acsorbyl-6-palmitate
  • Magnesiun ascorbyl phosphate. 
  • Aminopropyl ascorbyl phosphate
  • Tetrahexyldecyl ascorbate (BV-OSC)

These are fat soluble and stable at a neutral pH. The conversion rate of these back to L’Ascorbic acid is unknown.

Therefore, while a product containing “15% vitamin C” may be L’ascorbic acid, but oxidised and so not effective, or a stabilised product such as BV OSC, which will be partly converted to L’Ascorbic acid in the skin.

Question 4: What else is in the product?

Some formulations incorporate other antioxidants, for examplevitamin E (Tocopherol).

Forms of vitamin E to look out for in products include:

  • Alpha-tocopherol
  • Tocopherol acetate

Ferulic acidis another antioxidant, and is sometimes combined with vitamin C in products as it increases the L’Ascorbic acids stability by lowering the pH of the product.

And finally:

Always apply Vitamin C products in the morning; they are intended for daytime use due to their ability to neutralise free radicals caused by UV rays and pollution throughout the day. 

Don’t forget to follow up with a broad-spectrum sunblock.

Taking a vitamin C supplement and/or getting plenty in the diet can also increase the levels in the skin.

Basic skin care vs Cosmeceuticals

A cosmeceutical is a product that contains biologically active ingredients which have medicinal benefits.

Examples of basic skin care include moisturisers, sunblock, cleansers and toners.

Examples of cosmeceuticals / prescription grade skin care include Retinoids, Niacinamide, some vitamin C preparations, and hydroquinone.

For a product to be considered a cosmeceutical that has a beneficial physiological effect, the active ingredient must fulfil 4 criteria:

  • It should have a known specific biochemical mechanism of action in human skin
  • It should be able to penetrate the stratum corneum of the skin
  • There should be sufficient concentrations of the active ingredient
  • This penetration of the skin should be in a time course consistent with its mechanism of action

There should also be published, peer-reviewed, double-blind, placebo-controlled, statistically significant, clinical trials to substantiate the efficacy claims.

An example of an ingredient that could be considered basic skin care or a cosmeceutical is Vitamin C:

Vitamin C is an antioxidant, enables collagen synthesis, and reduces inflammatory pathways.

Vitamin C is used in skin care products either as BV-OSC, or L’Ascorbic acid. 

Some BV-OSC is converted to L’Ascorbic acid after application to the skin.

The most bio-available form of vitamin C is L’Ascorbic acid. This stimulates collagen production, and is water-soluble.

At least 10-15% L-Ascorbic acid is needed for optimum anti-ageing properties. 

BV-OSC is oil soluble, so offers hydration and antioxidant protection in the upper layers of skin. However, BV-OSC has to be converted into L’Ascorbic acid before the body can use it to stimulate collagen.

If a product claims to have 15% Vitamin C, but this is BV-OSC rather than L’Ascorbic acid, it will offer antioxidant protection, but may NOT stimulate collagen synthesis. 

The amount of this 15% BV-OSC that is converted to L’Ascorbic acid depends on the health, age and skin condition of the person.

The amount converted may not be enough for collagen synthesis. 

Therefore, even a skin care product that is “15% vitamin C” may not be optimum for anti-ageing.



There are a huge number of basic skin care products and cosmeceuticals, making various claims about the activity of their ingredients. 

It can be difficult to work out which will benefit the skin and which are just expensive creams making bold claims.

Over the next few blog posts, I aim to advise on what to look for and what to avoid when choosing your skin care products J

“Skin boosters” / “Injectable moisturisers”

Skin Boosters are micro-injections into the skin to hydrate the skin and improve skin quality.

Multiple injections can be given, in almost any area of the face, neck, chest and hands. 

Skin boosters usually contain hyaluronic acid, which is the ingredient used in dermal and lip fillers. However, while dermal fillers have a denser, firmer form of this, skin boosters have a thinner – more watery form. 

While dermal or lip fillers are injected deep UNDER the skin, to plump up the skin from below and shape the face, skin boosters are injected into the skin itself.

Skin booster injections activate fibroblast cells in the skin, promoting new collagen and elastin formation, to promote firmer and more youthful skin.

Skin boosters do not fill lines and wrinkles, or give an instant result. Instead, they hydrate the skin and cause formation of new collagen and elastin in the long term. Patients notice more of a “glow’; a more dewy and firmer appearance to the skin.

After a treatment, redness, swelling and pin prick bruising could take 48 hours to settle.

To cross-link or not to cross-link:

Traditional hyaluronic acid based dermal fillers have chemical bonds (“Cross-linking”) that make them firmer and last longer. This means that they can create a lifting and volumizing effect when injected into specific areas. 

The more cross-linked a filler is, the denser it will be. 

Skin boosters also contain a form of hyaluronic acid, however it is formulated in a different way to dermal fillers and either NOT cross linked at all or only very slightly cross linked – meaning that the substance is thinner. 

It can then disperse evenly in the skin once injected. It does not alter the shape or volume of the tissues, rather there is a moisturising effect and subtle, universal skin rejuvenation. 

If there is any degree of cross-linking, the skin booster can potentially, theoretically, block a blood vessel, causing complications. This is an extremely small risk however. Non cross-linked products do not carry this risk.

Who are skin boosters suitable for?

Skin booster injections are most beneficial for older or more dehydrated skin, however they can be used on almost anyone other than those with an allergy to an ingredient, those with medical conditions or medications that cause blood thinning or infections, or pregnant or breastfeeding women. 

Brands of skin booster available:

There are several brands available, all of which work in slightly different ways. 

Restylanes skinboosters have been in use for the longest, then ProfhiloJuvederm Volite and Teosyal Redensity 1Sunekos is the newest available in the UK. 

Profhilo:

Concentration of Hyaluronic acid:

32mg/ml – so 64mg for a standard 2ml treatment. This is the highest concentration of all of the skin boosters. 

Cross linked?

Profhilo is a cross linked hyaluronic acid – stabilised by heat treatment rather than with BDDE (1,4-butanediol diglycidyl ether) which is usually used to cross link hyaluronic acid fillers.

Local anaesthetic included?

Profhilo does not contain lidocaine, however topical numbing cream can be used.

Treatment regime recommended?

Profhilo involves fewer injections than other injectable moisturiser treatments – just five on either side of the face, rather than a series of small injections all over the face.

Two treatments are initially administered one month apart.

To maintain the effects, one treatment every six months is recommended (or two treatments a month apart, once a year),

Duration of effects?

Results can last between 6 and 18 months.

Juvéderm Volite:

Volite is administered in multiple injections all over the area of concern in the face.

This can be between 50 and 200 injections depending on the result desired.

Volite can help to treat crepey skin texture, such as vertical lip lines, backs of hands and around the eyes- the injections work to smooth out fine lines individually. 

Concentration of Hyaluronic acid:

12mg/ml – so 24mg for a standard 2ml treatment.

Cross linked?

Volite IS cross linked, and therefore there is a very slight risk that this product could block a blood vessel, causing adverse effects. This is a lower risk than with dermal fillers, but more than with a product that is not cross linked at all. 

Local anaesthetic included?

Yes. Volite requires more injections than Profhilo, however it contains a local anaesthetic called lidocaine to numb skin and reduce discomfort. Numbing cream before the procedure is ALSO used. 

Treatment regime recommended?

Generally, one treatment every 6 months is recommended to maintain results. 

Duration of effects?

One treatment can last up to 9 months.

Sunekos:

Sunekos is hyaluronic acid plus a patented formula of amino acids.

It is also administered in multiple injections all over the area of concern in the face – between 50 and 200 injections depending on the result desired.

Cross linked?

No. This is NON cross-linked Hyaluronic Acid.

Local anaesthetic included?

No. However, topical numbing cream can be applied before the injections are performed. 

Treatment regime recommended?

The recommended regime is 3 initial sessions, 3-4 weeks apart. After this, one treatment can be done every 6 months to maintain results. 

Duration of effects?

Sunekos effects last up to 6 – 8 months.

Teosyal Redensity 1:

Teosyal Redensity 1 is Hyaluronic Acid plus a patented formula of effective natural components – Amino Acids, Antioxidants, Minerals and Vitamins. 

These include glutathione, alpha lipoic acid, vitamin B6, zinc and copper. 

It is administered in multiple injections all over the area of concern in the face – between 50 and 200 injections depending on the result desired.

Concentration of Hyaluronic acid:

15mg/ml – so 30mg for a standard 2ml treatment.

Cross linked?

No. This is a NON cross-linked hyaluronic acid, plus amino acids and vitamins.

Local anaesthetic included?

Yes, it contains lidocaine.

Treatment regime recommended?

This injectable typically involves three initial sessions, a month apart, and then maintenance treatment every six months.

Duration of effects?

Effects last 6-9 months, with treatments recommended every 6 months to maintain resuts.

Skinboosters from Restalane:

“Skinboosters”, from Restylane, is cross linked hyaluronic acid. 

It is administered in multiple injections all over the area of concern in the face – between 50 and 200 injections depending on the result desired.

Concentration of Hyaluronic acid:

20mg/ml – so 40mg for a standard 2ml treatment.

Cross linked?

Yes

Local anaesthetic included?

Yes – Lidocaine

Treatment regime recommended?

This treatment is best done initially 3 times, one month apart. Maintenance is then 6 monthly.

Duration of effects?

The effects last about 6 months and the treatment is recommended to be performed 6 monthly to maintain the effects.